Abstract
Introduction: Radioembolization induced liver disease (REILD) is a rare disease secondary to hepatic outflow obstruction after intra-arterial injection of radioactive embolic microspheres. It manifests as hepatomegaly, jaundice, and ascites shortly after therapy. Treatment for REILD is limited, but some studies suggest that portal-systemic shunting may potentially slow disease progression. This case report describes an instance where transjugular intrahepatic portal-systemic shunt (TIPS) provided palliative benefit in a cancer patient suffering from REILD. Case Presentation: A 64 year old female was diagnosed with metastatic pulmonary adenocarcinoma. Palliative chemotherapy with Crizotinib was initiated and the tumor burden significantly improved, however new liver metastasis were later identified and the patient underwent radioembolization with yttrium-90 (90Y-RE). One month later she developed new ascites and elevated bilirubin and increased transaminases. Crizotinib was discontinued and the patient was treated supportively for presumed REILD. Over the next 4 weeks her bilirubin peaked at 18.3 mg/dL and she was hospitalized with tense ascites and hydrothorax. She underwent transjugular intrahepatic portal-systemic shunt (TIPS) which improved her portal hypertension (HVPG from 15mmHg to 4mmHg). A liver biopsy was performed and sinusoidal obstruction syndrome (SOS), consistent with REILD, was identified (Figure 1). The patient continued to improve and on day 7 following TIPS she was discharged. Discussion: 90Y-RE is a radioactive embolization therapy that can be used as palliative, sometimes curative therapy in patients with unresectable tumor. REILD results from injury and eventual fibrosis of hepatic sinusoids; histologically identical to sinusoidal obstruction syndrome. REILD occurs more often in patients who have cirrhosis, are treated with larger doses of radiation, and those treated with radiation-sensitizing chemotherapeutic drugs. Crizotinib is not a known radiation sensitizing agent, but it may have contributed to this patient's REILD. TIPS has been utilized as a method of reducing portal hypertension and improving symptoms in patients with SOS, but there have been no prior case reports describing the use of TIPS for treatment of 90Y-RE induced REILD. Crizotinib may be a radiation-sensitizing chemotherapy that has yet to be recognized. TIPS procedure may be considered for select patients suffering from REILD in the future.
Published Version
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